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rong site surgeries contin-ue to occur despite effortsby the Joint Commissionon Accreditation ofHealthcare Organizations

(JCAHO), the American Academy ofOrthopedic Surgeons, AORN, and nu-merous other organizations includingthousands of health care organizations.Broadly defined, wrong site surgeriesinclude wrong procedures or surgeriesperformed on the wrong site, wrongside, or wrong patient. Recently pub-lished JCAHO sentinel event statisticsidentify wrong site surgery as the sec-ond most commonly reported sentinelevent, accounting for 13% of all re-ported sentinel events.1 According toJCAHO, risk factors for wrong site sur-gery include • emergency surgery, • unusual time pressures to start or

complete a procedure, and • the involvement of several surgeons

or multiple procedures during a sin-gle surgical event.2

To prevent these types of errors fromoccurring, perioperative nurses andother health care providers must stay ap-prised of the most recent literature andresearch. Furthermore, they must consid-er these findings and use them to helpguide practice and develop appropriatesystem redundancies to minimize theknown risks for wrong site surgery. Au-thors of two recently published articlesdiscuss wrong site surgery and providefurther evidence about the type and na-ture of these errors while offering severalapproaches to prevent their occurrence.3-4

ANALYSIS OF WRONG SITE SURGERIESKwaan, et al3 performed an analysis

of wrong site surgeries that were report-ed to a large malpractice insurer be-tween 1985 and 2004. These researchersdetermined that of nearly three million

surgical procedures conducted at the in-sured health care organizations duringthis time period, only 25 non-spine,wrong site surgeries occurred. The re-searchers then reviewed the 13 patientcharts that were available from thesewrong site procedures and found that10 of the 13 wrong site procedures re-sulted in temporary injury that was ei-ther minor or insignificant. Of the re-maining threeprocedures, two patientsexperienced temporarybut major injuries, andone patient suffered frompermanent and signifi-cant injury. The authorsconcluded that JCAHO’sUniversal Protocol mighthave prevented eight ofthe 13 cases.

Included in the non-preventable, wrong sitesurgeries was a proce-dure in which

a magnetic resonanceimage of the knee wasprinted at a referringhospital for the incor-rect patient with thesame name as the cor-rect patient.3(p355)

In another situation, thesurgeon had obtained arevised consent after a patient with bilat-eral disease was sedated, and the patientdid not recall consenting to the changein procedures. The researchers conclud-ed that these cases of wrong site surgerywere not preventable.

Universal Protocol interventionsthat would have been instrumental inpreventing wrong site surgery includereconciling the consent form with theOR schedule or reconciling the OR

Update on correct site surgery

P A T I E N T S A F E T Y F I R S T

Suzanne C.Beyea, RN

WTo help prevent

wrong site errors,perioperative

nurses and otherhealth care

providers mustuse the most

recent literatureand research todevelop system

safeguards.

• patient confusion about theplanned procedure such asthe side or site.

Examples of procedure-relatedfactors include • the wrong site being

prepped or draped, • change of the patient’s posi-

tion or room before surgery, • incorrect site marking, and • not conducting a cross-

check of the consent formwith the chart or the ORschedule.

These researchers consid-ered whether WSPEs can beprevented, and they conclud-ed that the current health caresystem creates many opportu-nities for errors to occur. Ad-ditionally, the authors indicat-ed that preventing theseevents relies on each clini-cian’s ability and willingnessto adhere to correct site proto-cols. According to the analy-sis, including the patient inthe site verification processwhenever feasible appearedto be one of many effectivesystem redundancies that can

416 • AORN JOURNAL

FEBRUARY 2007, VOL 85, NO 2 Patient Safety First

schedule with the patient’sknowledge of the procedure.Other suggested strategiesinclude specifying the site ofthe procedure on the consentform and the OR schedule,specifying the side on the ra-diological report, and mark-ing the surgical site.

A REVIEW OF ADVERSE EVENTSAnother recently published

study examined wrong side/wrong site, wrong procedure,and wrong patient adverseevents (WSPEs) and whetherthey were preventable.4 Theauthors conducted a review ofthe literature and examinednumerous databases. Theythen developed an Internet-based system for collectingWSPE reports, which theyused to identify WSPE inci-dents. The authors concludedthat although WSPEs occurinfrequently, they may be sub-stantially underreported andare preventable.4

The findings from thisanalysis suggest that WSPEsoccur because of human, pa-tient, and procedure-relatedfactors. Examples of humanfactors include • communication break-

downs,• personnel changes, • various cognitive factors, • workload environment,

and• lack of accountability. Examples of patient factorsinclude• anesthesia,• sedation,• confusion about patient

identity because of identicalor similar names, and

Researchers in onestudy concludedthat the current

health care systemcreates many

opportunities for errors to occur.

be implemented to prevent er-rors. The researchers furtherdescribed the limited researchto date from which to guidepractice and identified a needfor ongoing study and analy-sis of procedures to preventWSPEs. They emphasized theimportance of and need for• reporting, • incorporating a team ap-

proach to prevention, • using ongoing human fac-

tors analyses, and • using technology to assist

with patient identification. To assist with further re-

porting, the authors developedand implemented a voluntary,anonymous web site for re-porting WSPEs (ie, http://www.wrong-side.org). This web sitelinks to a comprehensive sur-vey tool that supports confi-dential and anonymous re-porting of WSPEs. The intentof this data collection effort isto develop innovative solu-tions for preventing WSPEs bystudying the nature and typeof errors that occur. The website includes answers to fre-quently asked questions, linksand references, and the surveytool. The authors are hopefulthat collecting data about theoccurrences of these eventswill result in a better under-standing of how these errorsoccur and how they can beprevented in the future.

MORE TO LEARNThe authors of these two

recently published articlessuggest that perioperativehealth care providers stillhave much to learn aboutpreventing WSPEs. There

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Patient Safety First FEBRUARY 2007, VOL 85, NO 2

remains a need to establishprocesses that aim for 100%accuracy 100% of the time.Although WSPEs are rare,when they do occur, the out-comes can be devastating,and they can result in perma-nent patient injuries. The im-portance of understandingwhy and how errors occurand how to best prevent themcannot be underestimated.Each day, thousands of proce-dures are conducted national-ly during which patients areat risk for serious and per-haps life-altering medical er-rors related to a WSPE.

Perioperative nurses playin an instrumental role in pre-venting WSPEs. Most healthcare facilities have establishedprotocols in place. Nurses areideally positioned to serve asobservers and participants ofthe process and can identifywhich factors contribute to ac-curacy or to an error condi-tion. Furthermore, periopera-tive nurses need to stayinformed about the latest pub-lished literature and researchpertinent to this significant,clinical safety issue. Periopera-tive nurses also can contribute

to informational databases in-cluding their own facility’serror or near miss reportingsystem to help establish a bet-ter understanding of WSPEs.Until WSPEs are completelyeliminated, all perioperativeclinicians need to be vigilantand work with other membersof the health care team to es-tablish processes and systemsto prevent these adverseevents from occurring. ❖

SUZANNE C. BEYEAPHD, RN, FAAN

DIRECTOR OF NURSING RESEARCH

DARTMOUTH-HITCHCOCK MEDICAL CENTER

LEBANON, NH

Editor’s note: Universal Protocolis a registered trademark of theJoint Commission on Accreditationof Healthcare Organizations, Oak-brook Terrace, Ill.

REFERENCES1. Joint Commission on Accredi-tation of Healthcare Organiza-tions. Sentinel Event Statistics: Asof June 30, 2006. Available at:http://www.jointcommission.org/NR/rdonlyres/74540565-4D0F-4992-863E-8F9E949E6B56/0/se_stats_6_30_06.pdf. Accessed De-cember 29, 2006.

2. Joint Commission on Accredi-tation of Healthcare Organiza-tions. Sentinel Event Alert. Decem-ber 5, 2001;24. Available at:http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_24.htm. Accessed De-cember 29, 2006.3. Kwaan MR, Studdert DM,Zinner MJ, Gawande AA. Inci-dence, patterns, and preventionof wrong-site surgery. Arch Surg.2006;141:353-358.4. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure,and wrong-patient adverse events:are they preventable? Arch Surg.2006;141:931-939.

RESOURCESAORN Patient Safety First.

Near Miss Reporting Tool. Avail-able at: http://patientsafetyfirst.org/safetynet. Accessed Decem-ber 15, 2006.

Department of Anesthesiolo-gy. Wrong-Side.org. Available at:http//www.wrong-side.org. Ac-cessed December 14, 2006.

Joint Commission on Accredi-tation of Healthcare Organiza-tions. Sentinel Events. Availableat: http://www.jointcommission.org/SentinelEvents. AccessedDecember 15, 2006.

Agency for Healthcare Re-search and Quality. MakingHealth Care Safer. Rockville,Md: AHRQ Publication; 2001.Available at: http://www.ahrq.gov/clinic/ptsafety. AccessedDecember 15, 2006.

The AORN Foundation offers a traveling exhibit ofsome of the archives and medical equipment

that have been donated to AORN. The traveling ex-hibit is part of the permanent Museum of Peri-operative Care housed at AORN Headquarters inDenver, and there are many old and interestingitems to view in this exhibit. The traveling muse-um is available to chapters and members for dis-play at local functions, and because of a generous

donation from Jane Rothrock, RN, DNSc, CNOR,FAAN, there is no cost to chapters, members, orstate councils for the use of the exhibit.

If you are exhibiting the museum, you will beresponsible for providing a locked cabinet in whichto display the items. For more information on hav-ing the museum exhibit at one of your events, con-tact Nancy Harbin, senior project manager, at (800)755-2676 x 366 or nharbin@aorn.org.

Traveling Museum Exhibit Available for Display